Tobacco Retail Inspection Check

Tobacco Retail Inspection Check

Establishment: / Inspection Date:
Employee Name: / Inspection Time:
Employee Title:(Circle One) / Owner / Manager / Supervisor / Clerk
Purpose of Visit:(Circle One)
Routine Inspection/Education / Complaint Received / Failed Compliance Check Follow-Up / Suspension of Permit
Inspection / Retailer Requested Education / Other-Please Specify______
If Unable to Complete: (Circle One)
Out of Business / Closed / No Longer Sells Tobacco / Closed-Seasonal / Closed-Construction
Too Busy / Other-Please Specify______
Is Current Board of Health Tobacco retailer permit posted? /
/ Yes /
/ No
/ N/A
Current Mass DOR license posted? /
/ Yes /
/ No
Only Cigarettes in packs of 20 or more sold (No 'Loosies')? /
/ Yes /
/ No
Are Self Service Displays in Legal Location? /
/ Yes /
/ No
/ N/A
All humidors are locked? /
/ Yes /
/ No
/ N/A
Large yellow signs (MGL) posted? /
/ Yes /
/ No
If more than one registers, small yellow signs (MGL)posted? /
/ Yes /
/ No
/ N/A
No smoking signs posted? /
/ Yes /
/ No
If single cigars are sold, health warning sign posted where hand-rolled or manufactured cigars outside of original package are displayed? /
/ Yes /
/ No
/ N/A
Employee agreements on file (if required by local regulations)? (optional) /
/ Yes /
/ No
/ N/A
If there is a vending machine, does it meet all regulations? /
/ Yes /
/ No
/ N/A
Were there any violations found? /
/ Yes /
/ No
Are any 'Under 27' campaign items displayed in the store? /
/ Yes /
/ No
Does this establishment have a liquor license? /
/ Yes /
/ No
Price of cheapest tin/puck of moist chewing tobacco?
Is this price with or without tax? Please circle / Price $______
With / without tax
Brand of cheapest tin/puck of moist chewing tobacco? /
If violations found, please circle which action was taken:
Educational Warning Given / Referred to BOH / $25 Fine / $50 Fine / $100 Fine
Other Fine (Please Specify):______
/ Topics Discussed with Merchant:
/ Checked Permit
/ Reviewed Regulations/Tobacco Sales Laws
/ Retailers Responsibility
/ Proper Identification
/ Compliance Checks (minors may look older)
/ Penalties
/ Trainings
/ Required Signage Placement
/ Smoke-Free Workplace Law
/ Retailer Kit Materials
Materials Given:
/ Copy of Regulations
/ Large Yellow (MGH) Sign(s)
/ Small Yellow (MGH) Sign(s)
/ Cigar Health Warning Sign(s)
/ No Smoking Sign(s)
/ Retailer Kit/Training Materials
/ Sample Employee Agreements
FDA regulation violations noted during inspection:
/ Flavored cigarettes available for sale
/ Cigarettes available with 'low' 'mild' as descriptors
/ Vending machines in a non-adult only establishment
/ Sale of loose cigarettes
Notes/Comments: / FDA Advertising regulation violations noted during inspection:
/ Smokeless ads